Dr. Hall-
My dentist’s treatment plan calls for two lower 3-crown bridges for the second back tooth forward on each side. The dentist advises porcelain fused to metal crown/bridges—due to it being a stronger material to resist grinding pressures—and wants 20% additional $$ above the PPO contract rate for the “upgraded” crown materials vs. all porcelain crown/bridges.

I have three questions:
1. Which type of crown is better and will have best chance against cracking?
2. The 20% “upcharge” labeled as “lab fees” is not a covered code by my insurance. Can a dentist charge above the PPO contract rate and refuse to use the “standard ” porcelain/ceramic crown which is covered by insurance? It seems to me that it is a “work-around” the contract rate, effectively avoiding the limited contract rate fee.
Though I may prefer to have the PFM bridges if they are indeed stronger. I simply may not be able to afford this mandated “upgrade” and I do not think I should have to switch dentists as a result of this, since he is an “in-network provider.”
3. I have all porcelain upper bridges on each side, so my other concern is will the lower PFM crowns grinding against the “all porcelain” upper crowns cause the upper to more likely crack sooner, as I will have stronger material grinding against softer material as opposed to a like material against a like material? Does that make sense?
Thank you.

-Tom from Ohio

Tom,
If you are communicating this accurately to me, then there is indeed some funny business going on with your dentist trying to get away with charging above the contract rate for your bridges. It certainly sounds to me like he or she is playing games with terminology and fees. Let’s address that first.

To sort this out, we need to clarify the terminology here.

First, for the benefit of readers who may not know, a PPO is a preferred provider organization, which is a network of dentist providers that have made an agreement with an insurance company to offer discounted fees to the subscribers of the plan being offered by the insurance company.

Then, as far as the types of crowns, my guess is that your dentist, for the crowns that are a part of the bridges, is using the procedure code D6740 – retainer crown porcelain/ceramic. Notice the term “ceramic” in this procedure code. That’s important. Porcelain isn’t strong enough to serve as a bridge even on the front teeth, much less on the back teeth. It will crack under chewing pressure. But there are other ceramics that are plenty strong enough, and many dentists are now offering these metal-free bridges. I can’t help but assume that we’re talking about one of these higher-strength ceramics here and not porcelain.

But now you’re saying that your dentist wants to “upgrade” to a porcelain fused to metal crown. A couple of problems with these games he or she seems to be playing with the terminology. First, to me the upgrade would be the other way around. The higher strength all ceramic crowns would generally be more expensive. Second, there are procedure codes for porcelain fused to metal crowns and I’m sure the insurance company would have that on their fee schedule. There are three codes for porcelain fused to metal crowns: D6750, D6751 and D6752 for porcelain fused to high noble, base metal, or noble metal respectively. Now it’s possible that the PPO will not pay for the bridge if the metal is high noble. But the noble metal is actually stronger and unless they are really cheap, they should have a fee for that.

And the idea that this “upgrade” is mandatory—that seems to me to be a violation of his contract with the insurance company. The dentist can offer you an upgrade as an option, but he or she has to give you the choice of doing the service that is covered by your plan.

About your other two questions:
The porcelain fused to metal is a little stronger, but the high-strength ceramic is plenty strong enough for a bridge on back teeth.

As far as compatibility with the upper bridges, yes, you are better off having similar materials chewing against each other. Neither one is going to “crack,” but they will wear. You would be best off contacting the dentist who did the upper bridges and finding out exactly what was used on the chewing surface and matching that. You have these high-strength ceramics, but they are often made of a framework veneered with a porcelain.

Then I have a final question for you. Let’s say you tell your dentist no, you want the porcelain/ceramic crowns because you understand that is your right under your insurance plan. Will he or she give you then the high-strength zirconia ceramic? Or will you get the porcelain which won’t hold up? Bottom line—do you trust this dentist?

– Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

Hi Dr. Hall,
I like your website–it is informative.
I am a naturopath and need a crown. I’m concerned over some of the materials used. After my research, so I far like the look of the ceramic crowns (is this glass?) and wondering what Vita ceramic is made out of. I’m finding it hard to get an answer. I basically don’t want any with metals or lithium as I have thyroid issues.
Thank you,
Vanessa from New Zealand

Vanessa,
Any crown that is all ceramic is not going to have any metal in it. But I’m reading between the lines of your question, and I think you are asking about avoiding any metal ions in the crown. I don’t believe this is going to be possible to do, as there are metal ions in every dental ceramic I am aware of.

Let’s get into a little chemistry. Iron is a metal. Rust is iron combined with oxygen–iron oxide. While rust isn’t a metal, it has metal ions in it. And while you wouldn’t want to eat metallic iron, of course, iron ions are essential to life. They’re an important ingredient of our diet, since the hemoglobin in our blood has iron ions in it. The iron in our blood is what gives blood its red color.

Similarly, sodium is a metal. As a pure metal, it is toxic, but combined as a metal ion with chlorine it is sodium chloride, or common table salt, and is also essential to life.

Other metal ions that are important ingredients in our diet include calcium, potassium, magnesium, zinc, copper, manganese, molybdenum, and cobalt.

Lithium is a metal that is in the same family as sodium. It is so reactive that it doesn’t occur freely in nature, so it is found naturally in its ionic form combined with other elements. Lithium disilicate is a ceramic that is very strong and has been developed in the past few years to be used in dental crowns. I have in my mouth an e.max crown, which is made of lithium disilicate.

Zirconium is another metal. Combined in its ionic form with oxygen, it is known as zirconia, and is a ceramic that is even stronger than lithium disilicate and has also been developed recently to be used in dental crowns. It is so strong that it can be used in bridges without requiring a metal framework, something that is very risky with other ceramics.

You mention Vita. Vita is a brand of porcelain. Porcelain is a conventional ceramic that has been used for many years for dental crowns. It isn’t very strong by itself, but when it is bonded to tooth structure, it is strong enough for crowns on front teeth and premolars. Dental porcelains are made with kaolin as a key ingredient. Kaolin is a clay that has silica and aluminum oxide. Aluminum again is a metal, but it isn’t aluminum metal that is in these crowns but aluminum ions.

Glass is pure silica (silicon dioxide). Silicon is not a metal, but glass isn’t strong enough to be used as a crown, though there are some crowns that use a layer of glass on the outside (Empress crowns). However, the glass they use in Empress crowns is a leucite glass that has aluminum tectosilicate in it.

So you can take all of this information and figure out what you want to do. I am not aware of any biocompatibility issues with any of these ceramics. However, if you were to ask me my opinion about which one would be least likely to provoke any biological reaction, I would say the zirconia.

– Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

Dr. Hall,
I had three crowns done – upper and lower first molars on the left side, and lower right second molar. They were porcelain fused to high noble metal, insurance code #D2750. For $150 each, the dentist suggested I upgrade to crowns with added porcelain, so there would be no black line on my gum line in the future. On his advice I agreed.

When I got the insurance paperwork I noticed there was a charge on all 3 crowns for pulp cap direct, insurance code #D3110. Nothing was ever said to me about the pulp cap direct, so when I questioned it, his office insurance lady said that the insurance takes care of that, and whatever they don’t take care of she will write that portion off at no cost to me.

Then, two months after getting the crowns, the one on the lower right fell off. To my surprise it was a very very small partial crown. I questioned why I paid for an upgrade when there was no gum line involved, since it was such a small crown. The insurance lady told me the crown was all porcelain and the metal would have shown, if the upgrade hadn’t been done. I also asked why there needed to be a build up and why it needed pulp cap direct. She told me he had to build up the tooth and the root was almost exposed which does not make sense to me. The dentist re cemented the crown and charged my insurance company, but did not charge me. I would appreciate your feedback on my issues. Thank you so much for your time.
– Tony from California

Tony,
I don’t know because I can’t verify any of this, but all of this sounds awfully suspicious to me, like this dentist has a scam operation to milk everything he can out of the insurance companies.

And you.

I’m an accredited cosmetic dentist who saw a lot of appearance-conscious patients, and I never did porcelain margins or anything like that for esthetic purposes on lower molars, and two of these teeth you reported to me were lower molars. One was a second molar. Even if there were a black line there, no one would ever see it. In my own mouth, I have gold crowns on both my lower second molars and no one knows but my dentist and me.

And for a crown to fall off after two months? In twenty years, I never had a crown that I did fall off.

You said that the crown that came off, when you looked at it, had no metal and the insurance lady told you it was all porcelain. That makes sense, since you say it was a very short “partial crown.” Being all porcelain, it could be bonded to the tooth, which would make it stay on. But it didn’t stay on. Furthermore, the procedure code you quoted me was for porcelain fused to high noble metal (i.e. porcelain fused to gold), which would get a higher reimbursement rate from the insurance company than what it appears was actually done. And it certainly sounds like the dentist just made up that all these teeth required direct pulp caps. A direct pulp cap is a serious situation where the decay goes down to the pulp of the tooth and the dentist puts a special coating directly on the pulp of the tooth to try to save it without doing a root canal treatment. That tooth should then be watched to make sure it heals well before doing anything major like a crown. A protocol that would make sense would be to do the buildup and wait a couple of weeks to make sure the tooth isn’t sensitive and responds properly. And I would certainly expect the dentist to tell you about this at the time to tell you to let him know if you have any sensitivity afterward. If you did, then further attention would be needed. If you didn’t, then the dentist is going to want to get credit for heroically saving your tooth and saving you from needing a root canal treatment.

And that this was done on all three teeth? That strains credibility.

And the notion that the practice would write off whatever the insurance company didn’t pay, that’s an indication that this procedure is all an invention to get a little more money from the insurance.

I think this is worth an investigation by the insurance company. I’d report to them that you weren’t aware of any pulp caps. And you could also report your suspicions to the California dental board, if you have a mind to.

I’m not saying this dentist has done anything wrong—I’m saying it’s suspicious and worth looking into by the insurance company and by the dental board. If alerted, the insurance company and the dental board can demand to see the actual records and x-rays of these finished procedures and can check other patients to see if this dentist can back up his claims of what he has done.

Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

Dr. Hall,
My son has his four front teeth capped with the caps that have a white color in the front and the silver on the back. One of the crown is chipping revealing the silver under the white front. No dentist in or around town says they can help me without replacing the crown. Is there anything that can be done to simply make the front all white again without replacing the whole crown?

– Bobbi from New Mexico

Bobbi,
I have a couple of things to say about your son’s situation.

Yes, there is a way to repair a crown that is chipping and showing the underlying metal, but you’re going to need to go to a dentist with particular expertise in cosmetic dentistry and bonding technology. In Las Cruces that would be Dr. Brian Gilbert. Do a Google search for “Bright Star Dental” and you’ll find him. Over 95% of dentists are not going to know how to do this or have the equipment needed to do this.

The process is very similar to the technique I wrote about several years ago for repairing a porcelain bridge. The underlying metal has to be etched with a small sand blaster and then treated with a metal bonding agent like Panavia. The fractured edges of the porcelain have to also be etched either with the same sand blaster or hydrofluoric acid or both and then my preference is to treat it with a silane coupling agent. Then the metal has to be coated with an opaquer. The crown is then ready for bonding with composite restoratives, to match the color and surface luster of the porcelain.

But there is more to this situation than just repairing the crown. The question that comes to my mind is, Why is this crown chipping? You are writing on behalf of your son, which suggests to me that he is still young, meaning these crowns haven’t been on him for that long. The crowns are porcelain fused to metal, which is pretty strong. When they chip, it is usually because of some flaw in the making of the crown. And you say, “is chipping.” I’m going on sketchy details from you here, but your putting it that way suggests that this is a process that is occurring over time, not a single event. Is it going to chip some more? Something is either wrong with this crown, that it would do this, or there is something happening with your son that is particularly abusive to this crown.

And then I have the question, why were porcelain fused to metal crowns placed on your son’s front teeth in the first place? Dentists who care much about the appearance of their work will put all-porcelain crowns on front teeth almost exclusively, not porcelain fused to metal. I’m really questioning the dentist who did this work.

I’m admitting that my advice here is based on my trying to fill in the blanks with things that you haven’t told me explicitly. If I am filling in the blanks correctly, then here is what I would advise doing. First, I would go back to the dentist who did this and see if he or she will make this right by replacing this one crown for free. If that doesn’t work, then I would go to Dr. Gilbert and have him repair the crown. Then, when your son is college age, if he isn’t that age yet, I would replace all of these crowns with natural-looking all-porcelain crowns.

I’d be interested in hearing more about your case, if you care to write back.
– Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

Dr. Hall,
I had 4-front teeth crowned with porcelain over metal. I am VERY upset because I was not informed about the dark line that I now see?? I did go to dentist today & he is replacing 1-tooth w/ dark line, but after just a month of having these crowns, I noticed on the back of THIS PARTICULAR TOOTH a spot of METAL appeared. I think that is why he is replacing it. Is this a rare problem?? I wish that I had known my options!!?? How much does a crown w/ porcelain over metal cost?? I am in a small town near Tampa! I paid about $989 per crown; is that too much?
– Shirley from Tampa

Shirley,
Back in the early 1980s, putting porcelain fused to metal crowns on front teeth was a good idea. But not in 2013. There are now porcelain bonding techniques where porcelain can be bonded directly to the tooth instead of having to be bonded to a metal framework to give it strength. And there are new high-strength ceramics. So there is no longer any need for the metal foundation. All-ceramic crowns are plenty strong enough to serve just fine on front teeth.

In my opinion, a dentist who is serious about the appearance of his or her dental work wouldn’t even dream of putting a porcelain fused to metal crown on a front tooth. Not only does the metal make the crown look opaque, but you will have that awful dark line at the gumline. And if the dentist is successful in hiding that under the gum for now, in a few years the gums will often recede a little and the dark line will become visible.

So what you have is a dentist who doesn’t really care that much about how your smile looks. If you do, then you have a basic disconnect with this office. Now I want to be careful here, because many of these dentists who aren’t very concerned about the appearance of their work are excellent dentists. They are very engineering oriented and careful and thorough. They’re just not artistic. And this is the case with about 98% of dentists, maybe more – they simply aren’t artistically inclined at all.

So then what do you do about the four crowns you have? And my guess is that the dark line isn’t the only appearance-related problem with this work. They will have to be kind of opaque. I doubt they sparkle like natural teeth. And the shapes may not be natural. But replacing them with work from a truly artistic dentist will cost you another $1000 per tooth, and your insurance won’t cover that probably for another five years at least. But that is the only remedy. So when you’re ready to have them replaced, find an expert cosmetic dentist from our list and have this done right.

About the fee you paid – $989 is a typical fee for a crown. (Click here to read about costs of porcelain crowns.) The sad thing is that for that fee, or maybe just a little more, you could have had a beautiful all-ceramic crown that would have enhanced your smile rather than detracting from it. And about the metal on the back – remember that this is a porcelain fused to metal crown. They will often have a metal back. The metal back is actually gentler on the opposing teeth that chew against these teeth than the porcelain would be, and it shouldn’t be visible from the front. If you just have a spot of metal showing, then you probably had a thin layer of porcelain there over the metal. That shouldn’t cause any problem.

– Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

Just had a root canal on the tooth right next to the front tooth. Is it necessary for a crown to be put on ? Can a post only be put in and if so, repair the discoloration with a porcelain veneer ?
– Ann from New York

Ann,
There’s a simple answer to your question and a more thoughtful answer, and I’ll give you both.

The simple answer is that dentists were taught in dental school that if a tooth has a root canal treatment, it is weakened, and thus it needs a crown to strengthen it and prevent tooth fracture. Plus, after a root canal treatment, a tooth will turn dark, so a front tooth should have a crown to preserve its appearance.

The more thoughtful answer differs from this approach in two ways. First, on the “likelihood to break” issue:
– Yes, a tooth is weaker after it has had a root canal treatment. But there is a difference between back teeth and front teeth. Back teeth, because they have a flat chewing surface and cusps are prone to splitting – the chewing force comes down between the cusps and this pressure tends to force the cusps apart. A crown will prevent splitting of the tooth. A front tooth, however, doesn’t have these forces. The risk with a front tooth is that chewing creates a horizontal force that may break off the tooth. A crown, since it requires removing 1-2 millimeters all around the circumference of the tooth, will actually weaken it against these horizontal shear forces and make it MORE likely to fracture.

On the discoloration issue, yes, teeth with root canal treatments will discolor. However, if the root canal cement and the root canal filling material are carefully cleaned out of the inside of the crown of the treated tooth, that discoloration will take years to occur and will be mild.

My preference for a front tooth would depend on the amount of healthy tooth structure remaining in the tooth. If, say, 70-80% of the tooth is healthy tooth structure, I would recommend restoring the tooth simply with a translucent or white fiberglass post and composite. Then, when the tooth begins to discolor, that could be corrected with a porcelain veneer or a crown at that point. If substantial amounts of tooth structure are missing, I would use the same white or translucent post with an all-ceramic crown.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

Hi, I went to dentist today to inquire about replacing the crown on my two front teeth. They were put on about fifteen years ago and are discolored and embarrassing. I was told I need full ortho braces before I can get the crowns replaced. I do not have the money for that and I don’t see why I can’t just get new crowns and do the other stuff later. My front teeth in question are a little crooked and bucked out but not that terrible. What should I do?
– PJ from Wisconsin

Dear PJ,
I don’t like it when dentists put these restrictions on their treatment – they will only do the perfect treatment or nothing. People have budgets and sometimes less than ideal is the only thing within their budget.

You certainly should be able to get these crowns replaced without doing the orthodontic treatment. You could forgo the braces entirely, or you could do it later. The dentist should still be able to do great crowns and get them looking great.

I would find another dentist who is a more sympathetic and understanding type who will work with you and your budget.

And I would be sure to do all-porcelain crowns on your front teeth. Otherwise they will tend to look fake and will end up showing a dark line at the gumline. Make sure your dentist feels comfortable with this type of crown. Don’t press your dentist to do a certain type of crown – but ask what type the dentist recommends, all-porcelain or porcelain fused to metal. And if he recommends porcelain fused to metal, you’re in the wrong office. Just quietly exit and find a dentist who loves doing the all-porcelain.
– Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.